Unpacking the efficacy rates of using Fertility Awareness Based Methods to avoid pregnancy is nuanced at best. There are a lot of variables that go in to the stats - we hear studies ranging from 99.6% efficacy to 75.4%. These numbers have been widely debated and hotly discussed. You don’t see nearly as big of a gap with other contraceptive devices and pharmaceuticals.

You’ve probably seen this chart or something like it before. It’s usually hanging in your doctor’s office while you’re laying straddled on a table with your feet in stirrups. Desperately trying to distract yourself from the moment, your eyes wander to wall art. Jackpot. That poster. That’s the one.

See how Fertility Awareness based methods are at the bottom? Not looking so great. Why is that? It’s a complex question with an even more complex answer. But here’s a few to start:

Currently, most common source cited for the typical use numbers is the CDC 1995 National Survey for Family Growth. The survey is done retrospectively and requires individuals to recall which method they were using when they got pregnant over the last X months. This isn’t an awful way to collect numbers, but makes it hard to capture the nauce. (How important was avoiding pregnancy? What biomarkers were they charting? Were the biomarkers clear? Was the partner aware of fertility signs that day? Was there consent between the two partners?)

-Furthermore, the number of contraceptives who use FABM’s is small, so to get statistically relevant numbers all FABM’s are lumped together for typical use. That means that someone using a self prescribed version of the rhythm method and someone charting 5 biomarkers meticulously everyday are treated the same, even though it’s clear that these to users would have vastly different efficacy rates. The good news is the 21st edition of Contraceptive Technology (the reference book used by most clinicians) due in Sept 2018 will have a new chapter dedicated to FAMB’s which we are really looking forward to delving into.

In Chelsea Polis’s recent article, she identified a shortcoming in how numbers of FABM users is calculated. If a researcher calls up a participant in a study and they ask what method they are using and they say, “Fertility Awareness combined with a barrier method”, the researcher only puts down the barrier method as their sole use of contraception. In a way, this makes sense. If you are using a barrier method or withdrawal during your fertile window, then your contraception is as effective as that other method. On the other hand, it underestimates the number of FABM users and doesn’t account for how cycle literacy might improve the efficacy of other contraceptive use. For example if a couple using withdrawal also knows their fertile days, they might make different choices on those days than if they think they are fertile every day of the month. Likewise if a couple is using abstinence during their fertile window, they may be more likely to take risks on the “fringe” days of fertility. Again, there is nuance in our contraceptive decision making that is hard to translate to numbers.

Another issue is that a common FABM, the Fertility Awareness Method that is described in Toni Weschler’s “Taking Charge of your Fertility,” doesn’t have any studies that specifically test the rules as they are outlined there. As an educator I take the time to explain the rules that are used in the studies we do have, and how the rules I’m teaching line up (ie where they are more conservative and where they are more generous). It’s a level of detail that can feel tedious to wade through, but fertility awareness is all about informed consent, and in the absence of perfect data, discussions are key.

Lastly, a huge indicator of success rates in using a fertility awareness based method as contraception lies in the instruction they received and what type of support they had following instruction. Someone who downloads an app and wings it on their own is more likely to experience an unexpected pregnancy. During the learning period, are they abstaining? Using a barrier method? What about postpartum? Perimenopause? Post pill? If a person is learning during a transitional season, unintended pregnancy is more likely. This is when educator support is crucial.

FABM’s are really about living with your fertility. Say a person has used a FABM successfully for years and then one day, one time decides to not follow the rules. It doesn’t work. They have to actually follow the rules of the method according to their family planning wishes, every single act of intercourse. Coming from someone who has been charting for nearly a decade, it does become second nature - but you still have to do it. No IUD, Implant, Pill, or shot can contend with that level of complexity. It’s anything but set it and forget it.

I used to rave that using a FABM could be just as effective as the pill, and that can be true and it can also not be true. A pill suppresses ovulation from happening (most of the time), an IUD makes an inhospitable environment in the uterus for sperm, a condom prevents sperm from entering the vaginal canal all together. Intercourse still occurs. When someone is using a Fertility Awareness based method, it is intercourse itself, and its timing that determines the outcome, not a device or drug. (If someone is using a barrier method during their fertile period, the efficacy rate of the barrier method determines the outcome, not the FABM.)

In short, it’s complicated.

As an educator, I encourage people to ask the hard questions of whether or not they are willing to take that on. If they wake up to a positive pregnancy test, what will that mean for them? (Frankly, I think that if someone is sexually active period, that is a question worth exploring regardless of their family planning measures.) IUDs expel, condoms break, the pill fails to prevent ovulation - these things happen but when a FABM fails to prevent pregnancy (whether it was a method error or user error), there is no one to hold accountable but themselves - and that can feel very heavy.

Educators do what we can to teach with integrity, cover our bases in teaching the material, and provide appropriate follow up and support, but it’s important to manage expectations. Learning to chart your cycles could be uncomplicated and straightforward. It can also be the exact opposite. For women getting return of fertility post birth, coming off of months or years of hormonal contraceptive use, dealing with hormonal imbalance, and entering peri-menopause, charts may not be so clear cut. When a chart is difficult to read, there is a greater chance of error. If avoiding pregnancy is super top priority, you have to consider an “I don’t know what’s going on” day, a fertile day. When my clients leave our sessions, even if I have taught the material well, it’s up to them how they want to handle their days of fertility.

My relationship to FAMB efficacy rates has become a lot more nuanced. Of course I think it’s the greatest thing in the world and I’m so grateful to have these years of body literacy and knowledge - but I want people to know that they are signing on to listening and following their body. They are going to have to think about their choices on a cycle to cycle basis. It’s a lifestyle choice, not a prescription you can get from the corner drug store.

So will charting your cycles be effective in preventing pregnancy? Well that all depends. It can be. But if you’re looking for something that you don’t have to think about and requires little to no effort, a Fertility Awareness Based Method will never be able to contend with that. Even if we had saliva monitors on our toothbrush that told us when we were fertile, we would still have to make the decision of what do with our fertile window. We’re in the driver’s seat - and that’s kind of the point.

We'd love to hear your experience!

Have you experienced one or more unexpected pregnancies while using a FABM? *

Yes, it was a method error.Yes, it was a user error.I have had both a method and user error.No, I have not.

If you feel like expanding on question: *

Did you feel that you received appropriate education and support in learning a FABM? *

Yes, I felt supported and could make informed choicesNo, my instructor was difficult to communicate with.I didn't use an instructor.

If you feel like expanding on question: *

How many cycles did it take for you to feel really confident in charting and understanding your cycles? *

It’s not unusual to feel a little less energetic and less cheery during the long, dark winter months. However, for some people, seasonal sadness is more than the winter blues. Seasonal affective disorder (SAD) is a serious mental health concern that affects millions of people every year, most of them women. Here’s what you need to know.

What Is SAD?Seasonal affective disorder is a type of depression. According to the National Institute of Mental Health, SAD typically affects people during the late fall and winter months, although in rare cases, people may experience SAD during the summer.SAD dissipates when the seasons change, but it can seriously impact sufferers’ well-being during the winter. As with all major depression, people affected by SAD experience:●Changes in eating and sleeping patterns.●Fatigue and low energy. ●Difficulty concentrating.●Loss of interest in previously enjoyed activities and relationships.●Feelings of hopelessness or worthlessness.

Who Gets SAD?While anyone can experience SAD, certain risk factors make it more likely:●A history of mental health problems: People with bipolar disorder or a personal or family history of depression are more prone to SAD.●Living far from the equator: Locations further from the equator receive fewer hours of winter daylight, making residents more vulnerable to SAD.●Being a young adult: Although SAD can affect people of any age, onset is most common during the reproductive years.●Being female: According to The American Institute of Stress, women are four times as likely to suffer from SAD than men.

SAD and Your Fertility

Seasonal affective disorder makes it difficult to keep your fertility goals on track. As Bustle reports, “Seasonal Affective Disorder and the mood changes that go with it can not only cause stress in your romantic life, it can lead to a lack of interest in sex.” Furthermore, weight gain or loss due to changes in eating habits and carbohydrate cravings can cause hormonal imbalances that interrupt your menstrual cycles and decrease fertility. In one of nature’s cruel jokes, winter is also the season when sperm is the strongest. So if you’re trying to get pregnant with your male partner, it’s a good time to get busy—if you can get in the mood. Unfortunately, that’s easier said than done for women who experience SAD.

Fighting SAD

For women trying to conceive, taking winter off isn’t an option. Even if pregnancy isn’t on your radar, taking steps to keep SAD symptoms at bay can improve your wellness during the winter months.While there’s no surefire way to prevent SAD, there are a few things you can do to reduce risk and alleviate symptoms:●Stay active: Exercise promotes positive moods, relieves stress, and increases energy levels, making it a powerful tool in the fight against winter depression. Resist the urge to hibernate through winter and instead find creative ways to stay active in cold weather.●Eat right: SAD causes cravings for simple carbohydrates, but overindulging on bread, pasta, and sweets only leaves you feeling worse after the brief serotonin boost, and it’s not good for your hormones either. Instead, focus on eating foods rich in Omega-3 fats and vitamin D, and stick to whole grains to sate carb cravings.●Get enough vitamin D: At certain latitudes, it’s nearly nearly impossible to get vitamin D from sunlight during the short days of winter. Since low vitamin D is linked to depression, it’s important to make sure you get adequate vitamin D each day from diet or supplements. Talk to your doctor to determine your recommended vitamin D intake.●Bring summer indoors: Outside may be gray and dreary, but that doesn’t mean your house has to be. Modify your home to promote positive moods. Use bright daylight bulbs to mimic natural light; fill your home with colorful houseplants; decorate with bright, cheery colors rather than dark, wintry hues; and hang artwork that motivates and inspires you.The one blessing of seasonal affective disorder is that it passes with time. However, when you’re in the depths of winter depression, it’s hard to see the light at the end of the tunnel. In addition to taking the steps mentioned above, talk to your doctor and seek support from loved ones for help getting through the season.

That's it folks! The days might be getting longer (slowly but surely) but that might not mean your SAD is lifting. Flower blooms and birds chirping can feel far, far away. Thanks Kimberly for your great advice. Onwards and upwards - hello February!

Next month is my FAMiversary. I will have been charting my cycles for 6 years. In that time, things have changed. Some for the better, some for the worse. But I'm an optimist - I think Fertility Awareness Methods are on the up!

When I first began my momentous journey, I was googling fertility awareness in the dead of the night. I scoured forums, hunted blogs, and foraged for research studies. To be honest, there wasn't a lot out there in 2012. Holly Grigg Spall's Sweetening the Pill was gaining a social media following, although it was not published until 2013. The majority of actual, real life information I could find of people who used FAM or NFP was in those weird chat room forums that I didn't realize people even still used. You know the kind - the anonymous usernames like "wowzamama257" with animated profile pics of a cat shooting rainbows from its eyes.

The number one thing that I cared about? Efficacy. I wanted to know, explicitly, does this method work to prevent pregnancy. The conclusions online were murky. It seemed like I needed a PHD to wade through the research, anecdotes, and biases. I could write a whole other blog post on the confusion surrounding efficacy rates of women using FABM. I'll just leave it at this: for women who are just starting to enter the world of fertility awareness, there isn't one pretty chart that will tell you a method will definitively work for you 99.37% of the time like that cute t-shaped piece of metal. Then again, should we even be trying to compare the two? Aren't they kind of apples and oranges? Another post for another time.

I'd like to think research is up and coming - people who crunch numbers for a living like Chelsea Polis PhD are working hard to bridge the gap. But the fertility awareness world is still not unified. There's no one overarching committee (although AFAP is doing hard work to aim for this) to rule over the research and literature. Not to mention, differing values have made it hard for NFP and FAM to come together on much. I'm hoping in the next 6 years, we'll see more numbers about fertility awareness. The groundwork is being layed down. In 2016 Marguerite Duane MD of FACTS published a comparative study of FABM and hormonal contraception. In 2014, the use of OPKs was researched in conjunction with using a fertility awareness based method.

Since 2012, there have been a few landmark studies regarding hormonal contraception. In 2017, a Danish study confirmed a link with hormonal contraception and breast cancer. In 2016, research officially connected a link with hormonal contraception and depression. The numbers are happening. But often, before the research world (and accordingly its funding), can get to something, the media grasps on it first.

From what I've seen, since 2012, there's been a media explosion of content for fertility lovers. Sites just like this have popped up left and right. From Fifth Vital Sign, to Beauterus, to Body Language Life, to Ovary.Co, to Fearless Fertility, there's a whole host of homes for FAM content. This simply didn't exist a decade ago. I think it's great that newcomers to the fertility awareness world can find relatable, casual, informal information about charting. It's not so crazy anymore to get in a conversation with someone and say, "Well I use fertility awareness." and they chime in, "Me too!" It just doesn't feel as uncommon as it used to, finding a fellow FAM enthusiast. And it's increasingly more common to read about those finding fault with hormonal contraception.

Last week, the New York Times Op-Docs aired Sindha Agha's "Birth Control Your Own Adventure", a quirky and fun short film exploring the filmmaker's obstacle laden journey with different types of birth control. Sure, after someone broadcasts their unpleasant experiences with hormonal contraception on the web, there's usually a wave of criticism lashing back (isn't there always though?) of people alarmed and panicked that someone is denouncing the holy hormonal grail of family planning - but that just comes with the territory. Our political climate is...precarious at best.

That's another thing that has changed dramatically in the last 6 years I've been charting - our political climate. These days, fertility awareness advocates often find themselves in a pickle - wanting to make clear the factual risks of hormonal contraception without limiting access to them. Late in 2017, a report came from the White House that more funding would be put into Fertility Awareness Based Methods. Sounds great - sign us up! But there may be an agenda behind the reports that many FAM advocates can't get behind.

It remains to be seen how our current administration will affect women's health in coming years. Without delving too much into it (dinner party rules, right?) it's safe to say the FAM scene has become a little more tricky to navigate.

Someone once told me that technological advances often supersede political change. That has certainly been true in the FAM world. When I first started charting, I had my little thermometer from CVS and a few apps to choose from. Kindara was fairly new to the market. But they didn't have an app for android, which I was using at the time. Now there are hundreds of fertility charting apps (although the distinction should be made between observational charting apps vs rhythm method apps), and a whole blossoming FEMMEtech industry.

From Daysy, to Wink, to Tempdrop, Ava, and the MoonFertility Salinity Monitor - it seems one product after another is being rolled out. Amy Beckley PHD of MFB Fertility took matters into her own hands and in 2017 launched Ovulation Double Check progesterone test strips, the first of its kind. There's a lot of chatter about this tech - does it have women's best interest at heart? I personally feel that tech provides more options and when combined with the solid foundation of a good education in fertility awareness, tech can only bring a more personalized experience for women. I'm excited to see the direction of FEMMEtech.

Ultimately, I think FAM is headed in the right direction. It's far less obscure than it used to be. I'd love to see fertility awareness in every sex ed class across the nation but Rome wasn't built in a day. I feel mostly positive about the growth and change I've seen. When did you start charting? Have you seen the FAM field change since then? I'd love to hear your thoughts!

I know, I know. Self care is one of those words you see everywhere, from lifestyle Instagram accounts to waiting room magazines. Despite its trendiness, it's actually a pretty important concept. I usually incorporate alternative self-care practices into my monthly cycle, because I have different needs at different times of my cycle. I found for me, something happened after becoming a mother. The experience of pregnancy, labor and birth, and postpartum gave me a whole new way of being in my body. Throughout an average cycle, here's what it looks like for me:

Menstruation:New MoonLate WinterThis is a time for respite, pause, and setting intentions. I love the start of a new cycle, feeling full of hope for a new month ahead.

I usually jot down a few intentions during menstruation. What are some goals or aspirations for the upcoming cycle? Either professionally or personally. They are usually nothing too ambitious, but small, achievable goals.

I discern and consider my family planning hopes. This is important to do with my spouse. How do we feel this cycle?

I spend a little TLC time with my heating pad and give myself an early bedtime.

Follicular Phase:Waxing / Full MoonSpring/SummerEstrogen is rising which in turn gives me more energy, more excitement, and more creativity. I feel most productive and can foster some of my best work during this time.

This is when I usually get acupuncture, for my ovulatory migraines. I find during my sessions, I brainstorm some of my most inspired ideas.

The estrogen gives me a kick of energy so I'm better able to handle longer days and more social outings. I embrace this and take advantage of the opportunity to spend time connecting with friends.

This is the time it's extra important for me to make strong fertility observations. I try to be diligent about making cervical fluid observations and taking my temperature every morning.

If we're trying to avoid pregnancy, we have to get creative about how we connect. Romantic stay in date nights, mixing a fancy cocktail, or watching a movie with a big bowl of popcorn.

I glance at those goals I jotted down a week or 2 ago. Am I working on them? Where do I stand?

Luteal Phase:Waning MoonFall/Early WinterThis progesterone dominant phase feels so different for me hormonally and emotionally. I am more idle and reflective. My energy turns from outward to inward.

I revisit those thoughts I jotted down at the beginning of my cycle. Did I achieve them? Did they change course as the month developed?

I look out for a second wind of estrogen half way through my luteal phase. I use that time to tie up loose ends and finish projects.

I don't have to be as stringent about my fertility observations.

My energy dwindles as this phase passes. I make sure to balance out social outings with down time.

I may want to binge on fried food and sweets, but I make an extra effort to eat more fresh veggies than ever. I know the nutrients will carry me through the next menstruation.

It's a chronically busy time of year. Don't forget to check in with your body and listen to it!

When Dr. Poppy Daniels graciously sent her book my way, I was intrigued. Depo Provera is one of the contraceptives I don’t see super regularly in my work. In fact, I’ve only ever known one person who used it. I remember considering it years ago on my short stint on hormonal contraception, but my OBGYN on campus actually dissuaded me away from it. “Let’s try the pill first…” was her (well backed up) reasoning.

The Dangers of Depo is a collaboration between Dr. Poppy Daniels, wholistic gynecologist specializing in bio-identical hormone therapy and Traci Johnstone, former Depo user and sufferer turned advocate. Together they expose the effects from Depo, discuss the global and political ethics of Depo use in third world countries, and explore ways for Depo sufferers to heal and regain health after coming off this powerful drug. One thing is certain, after reading their book, I don’t want anyone going near that needle.

Daniels goes into depth talking about how Depo works and what makes it so potent. The shot contains Medroxyprogesterone acetate (MPA) which is a synthetic form of progesterone, called a progestin. The primary functions of how it works as contraception is similar to other pharmaceutical options. It suppresses hormonal production to low levels (like lower than menopause low), dries up cervical fluid, prevents most ovulation attempts, and keeps the lining of the uterus thin. All of these mechanisms are meant to either prevent an egg from fertilization and/or a fertilized egg from implantation. But Depo’s performance record seems less than ideal when you look at the risks vs benefits. Unlike other hormonal contraception, you can’t stop the hormones from entering your bloodstream once the shot has been administered. And furthermore, the withdrawal from the drug can often be worse than the actual use of it. After the intense suppression of hormonal production, the body exaggeratedly begins producing high levels of estrogen. But because ovulation is so unlikely to occur, there is no progesterone being created to balance out the estrogen. This causes a whole other host of side effects.

Speaking of side effects, I can’t even list all of them, either while on Depo or after coming off the shot, because they literally take up pages and pages in Daniels’ and Johnstone’s book. The most controversial side effect is a lower immune system (which poses an issue particularly in populations with already compromised immunity, such as high AIDS areas), loss of bone density, and certain cancers, particularly cervical and breast cancer. Anemia, digestive issues, insomnia, depression, heartburn, risk of stroke, infertility, hypertension are only a handful of other issues women experience.

Johnstone, who had a particularly rough go after only a short time on Depo discusses her experience in great depth in DOD. In short, Depo caused acute adrenal suppression, which wreaked havoc on her hormones, it destroyed her fertility, she lost her uterus due to a medical hysterectomy, her teeth and bones experienced rapid decay because of lost bone mass, and lastly, the ongoing infections she experienced due to a failed immune system snowballed into critical condition, which had she been properly treated from the get go, might not have been so detrimental. She lost jobs, friends, and her health. Reading her chapters left my head spinning and my body aching. It’s no wonder she has made campaigning against Depo her vocation.

According to DOD, Depo is currently one of the least popular pharmaceutical options for hormonal contraception in America, less than 5% of women use it. Yet it is still being pushed hard overseas as a popular, safe, and effective way to manage (re: inhibit) fertility. The most controversial aspect of this is the prioritization of preventing pregnancy over AIDS prevention and care. Not only does Depo not prevent AIDS from being contracted, such as condoms, but it can actually increase risk of AIDS contraction, and rapidly progress the disease. Daniels commented on the new Sayana Press - a DIY version of Depo (not available in the US or Canada) that widens the gap even further between impoverished communities and health care providers.

There was a wonderful portion of DOD dedicated to healing from Depo. I appreciated this because it didn’t leave those who had been harmed by Depo with solely regret and guilt. It gave people an action that they could do to 1) regain health and 2) spread awareness about consequences of Depo that get overlooked in the doctor's office.

I certainly learned a lot throughout DOD. I am now armed with even more information on how to aid my future clients who are getting off of this powerful contraception. The book did, however, leave me with a few important questions and concerns.

Is Depo particularly more harmful than other hormonal contraception? What specifically makes Depo drastically different, it at all, from other hormonal options? Isn’t bone loss and loss of nutrient absorption the case with any steroid?

Fertility Awareness Methods were addressed but alternatives for family planning could have been mentioned a little more.

This wouldn’t need to be addressed in the book necessarily but I did wonder what call to action could be done to address the use of Depo in third world countries where comprehensive consent may not be currently happening. What efforts could be joined in? Where can we turn if we want to boost fertility literacy in impoverished communities?

I found the women’s stories section to be so overwhelmingly vast, I eventually skipped over some and skimmed others. Useful perhaps in a presentation, that section left me a little defeated. I could have done without it, or at least in the format of listing them page after page after page.

These were just a few of my takeaways and a basic summary of what was covered in DOD. Read it for yourself to delve deeper into the complexities of this powerful drug! Ultimately, I highly recommend DOD. It’s an important piece in the conversation of how we can improve consent in the doctor’s office, encourage fertility literacy and empowerment for women everywhere, and reassess our family planning risks and benefits.